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MONITORING SYSTEM CERTIFICATION
For Use By All Jurisdictions Within the State of California
Authority Cite& Chapter 6 7, Health and Safety Code; Chapter 16, Division 3, TFt a 23, California Code o.JRegulations
Tltis form must be used to document testing and servicing of monitoring equipment. A separate certification or report must be prepare
for each monitorints system control panel by the technician who performs the work. A copy of this form must be provided to the. tank
system owner/operator. The owner/operator must submit a copy of this form to the local agency regulating UST systems within 30
days of test date.
A. General Information
Facility Name: 1 c'!'Ytp~rAt ~g~(~ y-C!AL _ Bldg. No.:
Site Address: y c`~. ~^~ ~ S~• City: R~k E ~6FX }-L 11 Zip: C133d\
Facility Contact Person: Contact Phone No.: (-_~
Make/Model of Monitoring System: (~IL)F.t,S "ec,Q~,ul~(~~t:!-2 Date of Testing/Servicing: Ll,~l 0,6
B. Tnventoty of Equipment Tested/Certified
r~r...,.L rr.- fl 1or> ti.....~ rn ;.,.lirarr+. ~ c4fic rnninmPnt incnected/serviced
~EL- V 1,,JEST
Tank ID~; 1
7
1 Tank ID: art=SEV ;v~ST
__
_
,,,
2_,
^ In-Tank Gauging Probe. Model:
Annular Space or Vault Sensor. Model L~ QQ L ^ In-Tank Gauging Probe. Model:
`Annular Space or Vault Sensor. Model: ~ G.
^ Piping Sump /Trench Sensor(s): Model: ^ Piping Sump /Trench Sensor(s). Model:
^ Filf Sump Sensor(s). Model: ^ FiII Sump Sensor(s). Model:
^ Mechanical Line Lcak Detector. Model: ^ Mechanical Line Leak Detector. Model:
^ Electronic Line Leak Detector. Mode]: ^ Electronic Line Leak Detector. Model:
^ Tank Overfill /High-Level Sensor. Modal: ^ Tank Overall /High-Level Sensor. Model:
^ Othcr s ci a ui ment a and model in Section E on Pa e 2 . ^ Other s eci ui ment and model in Section E on Pa e 2 .
Tank ID: TenklD:
^ In-Tank Gauging Probe. Model: ^ In-Tank Gauging Probe. Model:
^ Annular Space or Vault Sensor. Model: O Annular Space or Vault Sensor. Model:
^ Piping Sump / Trench Sensor(s). Model: ^ Piping Sump /Trench Sensor(s). Model:
^ Fill Sump Sensor(s). Model: ^ Fill Sump Sensor(s). Model:
^ Mechanical Line Leak Detector. Model: ^ Mechanical Litie Leak Detector. Model:
^ Electmnic Line Leak Detector. Model: ^ Electronic Line Leak Detector. Model:
^ Tank Overfill /High-Level Sensor. Model:
~ ^ Tank Overfill /High-Level Sensor. Model:
^ Other (s ecify
uipment type and mode! in Section E on Page 2). ^ Other (specify equipment type and model in Section E on Page 2).
Dispenser ID: G'1~) ~~TJ~ Dispenser ID:
^ Dispenser Containment Sensor(s). Model: ^ Dispenser Containment Sensor(s). Model:
^ Shear Valve(s), ^ Shear Valve{s).
O Dis enser Containment Floats and Chains . ^Dis enser Containment Floats and Chains .
Dispenser ID: Dispenser [D:
^ Dispenser Containment Sensor(s). Model: O Dispenser Containment Sensor(s). Model:
^ Shear Valve(s). ^ Sheaz Valve(s).
^ Dispenser Containment Float(s) and Chain(s). ^Dis enser Containrrtent Float s and Chains .
Dispenser ID: Dispenser ID:
^ Dispenser Containment Sensor(s). Model: O Dispenser Containment Sensor(s). ModeL•
^ Shear Valve(s). ^ Shear Valves}.
^Dispenser Contauunent Float(s) and Chains . ^Dis enser Containment Floats and Chains .
•If the facility contains more tanks or dispensers, copy this form. Include information for every tank and. dispenser at the facility.
C.,-.CertIf CatIOri - I certify that the equipment identified lu this document was inspected/serviced in accordance with the manufacturers'
guidelines. Attached to this Certification is Information (e.g. manufacturers' checklists) necessary to verify that this Information is •
correct and a Plot Plan showing the layout of monitoring equipment. For any equipment capable of generating such reports, I have also
attached a copy of the report; (check all that apply): ^ System set-up ^ Alarm history report
Technician Name (print}: ~ Ati1~1fJ~ f1r.,~so.•y Signature: ~'lrip~'"-
Certification No.; ,~ :Z.~~/9'~V '"Cl~ License. No.: p Og $~_
Testing Company Name: i2ICH ENVIRONMENTAL Phone No.: ~ 661 } 392-8687
Site Address: y o`V ~t-[l't1 b"~ I-~13~~• ~ ~r ~~D~ ~y~~` Date of Testing/Servicing: /C)/ c>$/~
Page I of 3 03101
Monitoring System Certification
- -- _... _
.`~ -i ~ t
D. Results of Testing/Servicing
Software Version Installed:
!''.......In*e •~.e f..ti n...i«n ..6 nn41icr.
Yes ^ o Is the audible alarm o erational?
!$ Yes 0 o Is the visual alarm o erational?
~ Yes ^ o Were ail sensors visual) ins ected, functional) tested, and confin-ned o erational?
>~ Yes ^ o Were all sensors installed at lowest point of secondary containment and positioned so that other equipment will
not interfere with their proper o eration?
^ Yes ^ o If alarms are relayed to a remote monitoring station, is all communications equipment (e.g. modem)
I8 N/A operational?
^ Yes ^ o For pressurized piping systems, does the turbine automatically shut down if the piping secondary containment
$1 N/A monitoring system detecu a leak, fails to operate, or is electrically disconnected? If yes: which sensors initiate
positive shut-down? (Check all that apply) ^ Sump/Trench Sensors; ^ Dispenser Containment Sensors.
Did ou confirm ositive shut-down due to leaks and sensor failure/disconnection? ^ Yes; O No.
~ Yes ^ o For tank systems that utilize the monitoring system as the primary tank overfill warning device {i.e. no
^ N/A mechanical overf lI prevention valve is installed), is the overfill warning alarm visible and audible at the tank
fill point(s) and operating pro rl ? If so, at what rcent of tank ca ci dces the alarm trigger'? 9
^ es ~ No Was any monitoring equipment replaced? Ifyes, identify specific sensors, probes, or other equipment replaced
and list the manufacturer name and model for all re lacement arts in Section E, below.
^ es ~ No Was liquid found inside any secondary containment systems designed as dry systems? (Check all that apply) ^
Product; ^ Water. If es describe causes in Section E below.
~ Yes ^ o Was monitorin s stem set-u reviewed to ensure ro er settin s? Attach set u re orts, if a licable
~ Yes ^ o Is all monitoring equipment operational per manufacturer's specifications?
In JeCIIOq L DCIOW, aCSCr7DC dOW anp WILCO [tlCSC (IerlClenC1CS Were Or WIII bC COITCCtC(i.
E. Comments:
Page 2 of 3 03101
~~u~~
F. In-Tank Gauging /SIR Equipment:
0 Check this box if tank gauging is used only for inventory control.
O Check this box if no tank gauging or SIR equipment is installed.
This section must be completed if in-tank gauging equipment is used to perform leak detection monitoring.
Complete the following checklist:
^ Yes ^ o Has all input wiring been inspected for proper entry_and termination, including testing for ground faults?
^ Yes ^ ° Were all tank gauging probes visually inspected for damage and residue buildup?
^ Yes ^ o Was accuracy of system product level readings tested?
^ Yes ^ o Was accuracy of system water level readings tested?
^ Yes ^ o Were all probes reinstalled properly?
^ Yes ^ o Were all items on the equipment manufacturer's maintenance checklist completed?
• T.. 45... CnnHn.. I.I F.nf n... Annn.~:ho i.nvr nn~l ull. n.. khma ilnrninn n.no .vnro ns. mill ha nnrranfn.l
G. Line Leak Detectors (LLD}
Com fete the followin checklist:
J$ Check this box if LLDs are not installed.
O Yes ^ No' For equipment start-up or annual equipment certification, was a leak simulated to verify LLD performance?
^ N/A (Check all Thar apply) Simulated leak rate: ^ 3 g.p:h., ^ 0. I g.p.h , ^ 0.2 g.p.h.
^ Yes 0 o Were all LLDs confirmed operational and accurate within regulatory requirements?
^ Yes ^ o Was the testing apparatus properly calibrated?
^ Yes ^ o For mechanical LLDs, does the LLD restrict product flow if it detects a leak?
^ N/A
^ Yes ~^ o For electronic LLDs, does the turbine automatically shut off if the LLD detects a leak?
^ N/A
^ Yes ^ o For electronic LLDs, does the turbine automatically shut ofd' if any portion of the monitoring system is disabled
^ N/A or disconnected?
^ Yes ^ o For electronic LLDs, does the turbine automatically shut off if any portion of the monitoring system malfunctions
^ N/A or fails a test?
0 Yes ^ ° For electronic LLDs, have all accessible wiring connections been visually inspected?
^ N1A
^ Yes
It T~ ~.L _ C ^ o
~ _ - TI Were all items on the equipment manufacturer's maintenance checklist completed?
~u ~~C orc~ivu n, uclvw, uescnoe now ana wnen tnese aerlclenetes were or wtt! be corrected.
H. Comments:
Page 3 of 3 03101
`i~ 1,
~r
Monitoring System Certification
UST Monitoring Site Plan
Site Address: _4 ao "'~ ~ar~l ST TiAlc~ktt aE~~~{~ 9~ ;301
_ - -
Date map was drawn: Jij / S / o(o
Instructions
If you already have a diagram that shows all required information, you may include it, rather than this page, with your
Monitoring System Certification. On your site plan, show the general layout of tanks and piping. Clearly identify
locations of the following equipment, if installed: monitoring system control panels; sensors monitoring tank annular
spaces, sumps, dispenser pans, spill containers, or other secondary containment areas; mechanical or electronic line leak
detectors; and in-tank liquid level probes (if used for leak detection). In the space provided, note the date this Site Plan
was prepared.
Page `~ of ~'( osioo
l_~~7~.
MONITOR CERT. FAILURE REPORT
SITE NAME• M C W 1~ ~ ~(~l. F+r~ s~i'A~L DATE: /U "-- -O(o
ADDRESS: 4 a0 "~ ~'CK b'~ TECHNICIAN: ~RA-~ ~o.,.~ +`1A
CITY • 1~ Pc ~ ~;, P.S ~J' EL'S SIGNATURE: i~----~--
THE FOLLOWING COMPONENTS WERE REPLACED/REPAIRED TO COMPLETE
TESTING.
REPAIRS• /yU/(1 ~
LABOR• ~d~ E
PARTS IIVTALLED: .U ['~,u C,
NAME: TITLE:
SIGNATURE:
THE ABOVE NAMED PERSON TAKES FULL RESPONSIBILITY OF NOTIFYING
THE APPROPRIATE PARTY TO HAVE CORRECTIVE ACTION TAKEN TO REPAIR
THE ABOVE LISTED PROBLEMS AND NOTI'F'YING RICH ENVIItONMANTAL FOR
ANY NEEDED RETESTING. THIS ALSO RELEASES RICH ENVIItONMENTAL OF
ANY FINES OR PENALTIES OCCURING FROM NON-COMPLIANCE.
A COPY OF TffiS DOCUMENT HAS BEEN LEFT ON-SITE FOR YOUR
CONVIENENCE.
SWRCB, January 2006
Spill Bucket Testing Report Form
This form is intended for use by contractors performing annual testing of UST spill containment structures. The completed form and.
printouts from.tests (ijapplicable), should be provided to the facility,owner/operator for submittal to the local regulatory agency. -~
ti T ~ !'riT 7T17 7'1-iL~ADAA' A •1'T!'11-T
Facility Name; - -- -- - - - - -- -- - Date of Testing: - 5 -O(.;
Facility Address: T {~k6RS rrz CC-'D 3 O \
Facility Contaot: ~ Phone:
Date 'Local Agency W as Notified of Testing
t~Iame of Local P.gency Inspector ({jpresent during testingJ: ,N~jn/ 4
TTi'.CT7Nt-,: [''nNTRA('Ti1R TNFllRMATTt~N
Company Name: (Z - t..
.Technician Conducting Test: '(~(Lpt,t; ,v v.hbUN ~ S ~ ~ 'r
Credentials': CSLB Contractor ~"~i~ccTi SWRCB TankTeater Other (Spec)
License Number(s)`
4. ~PTi,T. RT1(`KF.T TF,CTINC,' TNFt~RMATTt~N
Test Method Used: Vacuum Other
Test Equipment Used: V ~6uP.i„ Equipment Resolution:
Identify Spill Bucket (By Tank
Number, Stored Product, etc. 1
~~Eb i:l< ~A T 2
& L T 3 4
Bucket Installation Type: ircct Bt
Contained in S
Contained in S Direct Bury
Contained in S Direct $ttry
Contained in Sum
Bucket Diameter: / 'd,'` ti ~~
Bucket Depth: ~ 'a, ~' t',` `
Wait time between applying
vacuum/water and start of test:
3~ kTn~
3~ ~"~,.J
Test Start Time (T~: : ~ : 0O t,,,
Initial Reading (R~:. ~• ~ ~^
Test End Time (TF); l v' ~~,~ l~.. ~
Fitial Readuzg (Rr,): ~ ~ ~ ~~
Test Duration (T'F - T~: ~
Change in Reading {RF-R~: t~ ~ ~.
PassJFail Threshold or
Criteria: ~' t~
Comments - (cnclude in ormatio R rrs made riot to testin ,and recomme
nded ollow-u or ailed tests
CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING
I hereby certify that all the information contained' in this report is true, accurate, and in frill compliance with legal requirements
Technician's Signature: '-"-'~d~
-~ Date:~d- ~- d G
~ State laws and regulations do not cturently require testing to be performed by a qualified contractor. However, local requirements
may be more stringent.
t u~~`~
SB,989 TESTING FAILURE REPORT
SITE NAME ~.~~rp (L S R ~. C~tCJ~p j, T~ l.. DATE : /(~ - S~~ t~
ADDRESS : `-~ ap ~~-\ ` N St TECHNICIAN: Z~CA-v'~c~- i^'~A~e~/~1
CITY: '~e~,lc~rz~FZt~a7 SIGNATURE: ~~ ~,
SITE CONTACT:
THE FOLLOWING COMPONENTS WERE REPLACED/REPAIRED TO COMPLETE THE 58989
TESTING,
LIST OF PART3 REPLACED/REPAIRED:
REPAIRS; ~~j,~ C
LABOR : ,Yn,1J ~
PARTS INSTALLED;
•b
-~NpERGROUND STORAGE TANKS BAKERSFIELD FIRE DEPT.
Prevention Services
At l/1 f 900 Truxtun Ave., Ste. 210
APPLICATION ~ Bakersfield, CA 93301
TO PERFORM ELD 1 UNE TESTING ;. TeI.: (661) 326-3979
t SB989 SECONDARY CONTAINMENT TESTING Fax: (661) $52-2171
!TANK TIGHTNESS TEST ANO TO PERFORM
FUEL MONITORING CERTIFICATION page 1 of 1
PERMIT NO.
^ ENHANCED LEAK DETECTION ~^ LINE TESTING "- ^ SB-989 SECONDARY CONTAINMENT TESTING
n Tn Alv nl~ulUCec TCCT /~M Tl1 DCRCf1R11A CI ICI ~Al1WTf1R11J-~_~ f7 !` R I`
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~ `( t NAME b HONE NUMBER OF ON7ACT PERSON ~ _
ADDRESS „ ~ )_
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OWNERS NAME
OPERATORS NAME PERMIT TO OPERATE N0.
NUMBER OF TANKS TO BE TESTED I ^ ^ N
TANK:TESTING COMPANY .
NAME OF TE NG C MPANY
tr NAME b PHONE NUMBER OF CO TACT PERSON
MAILING ADDRE33
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NAME b P NE NUMBER OF TESTER OR SPECIAL INSPECTOR
- ~ CERTIFICATION #:
DATE b TIME TEST TO BE CON UCTED
•ooc~ ICC #: TEST METHOD
51GNATURE OF APPLICANT ~'C - DATE ,!~
APPROVED BY GATE
FD 2095 (Rev. 09/05)
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Alamts -New 8 Modifications - (Minimum Charge)
.Over?0,000 Sq. FG
Sprinklers- New ~ Modifications - (Minimum Charge)
Over 5;000 Sq. Ft.
Minor Sprinkler Modifications (< 10 heads}
Commercial Hoods -New 8 Modifications
Addltlona! Hoods
Spray Boaths -New 8 Modifications,
Aboveground Storage Tanks (lnstellatioMnsp: tg Time
Additfonai Tanks
Aboveground Storage Tanks (Removelllnspection)
Underground Storage Tanks (lnstalletionJlnspectipn)
underground Storage Tanks (Modificatan)
lJndergtound Storage Tanks (Minor Modifigtion)
Underground Storage Tanks (Remove!)
Oilrveil (Installation)
Mandated i.eak Detection (Tesfing) / uel Monit.
Tents
After hours inspection fee
Pyrotechnic - (Per event, Plus Insp. Fee Q $90 pe
RL~lNSP~CTION(S) /FOLLOW-UP INSPEC'
Portable l_PG (Propane): NO. OF' CAGES?
Copying & File Research (Fite Research Fee 533,00 per
Miscellaneous ,
$262.50
Sq. Ft x .013125 =Permit fee
$210.00
Sq. Ft x .042 =Permit fee
$ 93.00 jlnspection On1yJ
$ 39828
3 38.00
$458.00
$165.00
a 2s.oo
$109.00
$878.1)0 (pertank)
$878.00 (persite)
$155.00 .
$675.00 (pertank)
$ 72.00
$ 81.00 (per site)
$ 93.00 (per tent)
x122.00 -
$ 60.00 + (5 hrs, min. stand -by tee nnspec~tton) _$510.00
$ 93.00 (per hour}
$ 66.00
$249.00
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FD 2021 (Rev. 09/05)
1 -ORIGINAL YYHfTE (to Treatury} 1•YELLOW (to F116) 1~'INK (t0 Cuatomery
_.. - -
BILLING & PERMIT STATEMENT BAKERSFIELD FY E
Preveation Services
!-IRl 900 'lYuxtun Avenue, Suite 210
~Rrr r
PERMIT NO.: e„~ Bakersfield, CA 93301
;~ _
:UNDERGROUND STORAGE TANKS BAKERSFIELD FIRE DEPT.
tr --~;r Prevention Services
~,
I ~
~~ ~~ wR r T 900 Truxtun Ave., Ste. 210
:~}
APPLICATION ~~ ~- Bakersfield, CA 93301
TO PERFORM ELD /LINE TESTING ~'~ Tel.: (661) 326-3979
/ S6989 SECONDARY CONTAINMENT TESTING ~'
/TANK TIGHTNESS TEST AND TO PERFORM Fax: (661) 852-2171
FUEL MONITORING CERTIFICATION Page 1 of 1
PERMff NO. ~ "-~ (~
^ ENHANCED LEAK DETECTION ^ LINE TESTIN - ^ SB-989 SECONDARY CONTAINMENT TESTING
n TANK TIQHTNFSS TEST TO PERFORM Fl1Fl MONITORING CERTIFICATI
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FACILITY ,^n -
r `( ~ NAME 8 HONE NUMBER OF CONTACT PERSON ~ + ~ r
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ADDRESS ~ C~
OWNERS NAME
OPERATORS NAME PERMIT TO OPERATE NO.
NUMBER OF TANKS TO BE TESTED IS PIPING GOING TO BE TESTED? ^ .YES ^ NO
VOL ME CONTENT
TANK,TESTING COMPANY
NAME OF TE NG C MPANY
~ V' NAME 8 PHONE NUMBER OF CO TACT PERSON
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MAILING ADDRESS
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NAME 8 P NE NUMBER OF TESTER OR SPECIAL INSPECTOR
- o D CERTIFICATION #:
DATE 8 TIME TEST TO BE CON UCTED
O~
~•~OC~ ICC #: TEST METHOD
SIGNATURE OF APPLICA T C~' ~ DATE _~
APPROVED BY DATE ~?
FD 2095 (Rev. 09/05)
B~L~LING & PERMIT STATEMENT
HERMIT NO.:
BAKERSFIELD FIRE DEPT.
Prevention Services
PfB~ 900 Truxtun Avenue, Suite 210
~Rrr r
Bakersfield, CA 93301
Tel. (6611 326-3979 S Fax: (6611 852-2171
~
LOCATION OF PROJECT - n -
~.~2JYYLOV'l~X S - •
PROPERTY OWNER
STARTING DATE TTC MPLETION D TE NAME ~ ~y~1~-
PROJECT NAME
o tn,~~ Y' - ADDRE S
3 ~. PHONE N0.
PROJECT ADDRESS ~ / J _ ^ ~
`°rY]. ~T CfTY ~ STATE ZIP CODE ~ ~ - -
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CONTRACTOR NAME ~~.~ CA LICENSE NO. •- •
TYPE OF LICENSE. EXPIRATION DATE
PHONE N0. " O / -
CfJ
CONTRACTOR COMP E FAX NO.
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ADDRESS CfTY ZIP CODE 77 Q~
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^ Alamts -New & Modifications - (Minimum Charge) $262
50 •
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Over 20
000 Sq
Ft Ft x
013125 =Permit fee
Sq ~
^ ,
.
. .
. 98
^ Sprinklers -New & Modifications - (Minimum Charge) $210
00 ~
. 98
^ Over 5
Ft
000 Sq Sq
Ft x
042 =Permit fee ~
,
. .
. 98
^ Minor Sprinkler Modifications (< 10 heads) $ 93
00 (Inspection Only) ~
. 98
^ Commercial Hoods -New & Modifications $ 398
26 ~
. 98
^ Additional Hoods $ 36
00 ~
. 98
^ Spray Booths -New & Modifications $458
00 ~
. 98
^ Aboveground Storage Tanks (InstallatioNlnsp: 1" Time) $165.00 82
^ Additional Tanks $ 26.00 82
^ Aboveground Storage Tanks (Removal/Inspection) $109.00 82
^ Underground Storage Tanks (Installation.llnspedion) $878.00 (pertank) 82
^ Underground Storage Tanks (Modification) $878.00 (persite) 82
^ Underground Storage Tanks (Minor Modification) $155.00. 82
^ Underground Storage Tanks (RemovaQ $675.00 (per tank) 84
^ Oilwell (Installation) $ 72.00 .84
Mandated Leak Detection (Testing) / uel Monit. Ce . $ 81.00 (per site) 82
^ Tents $ 93.00 (per tent) ~
^ ~ After hours inspection fee $122.00 84
^ Pyrotechnic - (Per event, Plus Insp. Fee @ $90 per hour) $ 60.00 + (5 hrs. min, stand -by fee Mspectlon) _ $510.00 84
^ , . RE-INSPECTION(S) /FOLLOW-UP INSPECTION(S) $ 93.00 (per hour) 84
^ Portable LPG (Propane): NO.OF CAGES? $ 66.00 ~
^ Explosive Storage $249.00 ' ~
^ Copying & File Research (File Research Fee $33.00 per hr) 25¢ per page ~
^ Miscellaneous : ~
FD 2021 (Rev. 09/05)
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FACII'..Ix'Y ADDRF.SS_.~~ ~'t'~ ~i y -~{,` S+ • -_ - -
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Page 3 of ,,,._
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ALARM HISTORY REPORT
ALARM HISTORY REPORT
----- SENSOR ALARM -----
----- SENSOR ALARM ----- L 7:DISP PAN 7-8
L 4:DISP PAN 1-2 DISPENSER PAN
DISPENSER PAN FUEL ALARM
FUEL ALARM APR 1. 2004 1.2:16 PM
APR 1. 2004 12:18 PM
FUEL ALARM
FUEL ALARI~1 F~EH 13. 2003 9:08 PM
JUL 25. 2003 9:17 AM
FUEL ALARM
FUEL ALARM FEB 9. 2003 2:57 PM
FEB 13. 2003 9:40 PM
* x ~ ~ * END ~ ~ ~ ~ ~€
* ~ ~ ~ ~ END ~ ~ ~ ~
ALARM HISTORY REPORT
ALARM HISTUR`f REPURT
----- S£NSOR~ALARM -----
----- SENSOR ALARM ----- L 7:DISF PAN 7-8
L 5:DISP PAN 3-4 DISPENSER PAN
DISPENSER PAN FUEL ALARM
FUEL ALARM AFR 1~ 2DD4 12:1b PM
APR i. 2004 12:15 FM
FUEL ALARM
FUEL ALARM FEB 13. 2003 9:08 PM
JUL 25, 2003 10:1! AM
FUEL ALARM
SENSOR OUT ALARM FEB 9. 2003 2:57 FM
JUL 25, 2003 10:09 AM
* * * EtVD
* ~ ~ * ~ END ~ ~ ~ ~
~-
ALARM HISTURl' REPURT
ALARM HISTOR;' REPURT
' ----- SENSUk ALARM -----
----- SENSOR ALARM ----- L 8:
L 6:DISP FAN 5-6 OTHER SENSURS _
DISPENSER FAN
FUEL ALARM
AFR I. 2004 12:17 FM
~. ____
-
- -
i ALARP'1 H I STt~kY REP•3RT ~ ~ _
' ---- IN-TANK
ALARt'~ ----- _
T i:REU UNLD
~
GVERFILL ALARM x ~ ~ * ~ END ~ ~€ x
i AFR 1. 2004 8:45 AM
i MAR 8. 2004 6:313 AM
FEB 11. 2004 12:31-AM
HIGH PRODUCT ALARM
APR 1. 2004 8:44 AM
MAR 25. 2004 12:23 PM ALARM HISTORY REPORT
MAR 8. 2004 6:37 AM
j ILAVALID FUEL LEVEL L-2: - ~EIVbGk
PLUS STP ALARM " -__
MAR 28. 2004 7:51 FM ALARM HISTORY REPORT :TP SUMP
JAN lb. 2004 8:33 AM FUEL ALARM
NOV 17. 2003 4:'52 PM ---- IN-TANK ALARM ----- APR i. 2004 12:13 PIM
DELIVER' NEEDED T 3:SUPER UNLD FUEL
FEB ALARM
MAR 28. 2004
8:31 PM
INVALID FUEL
LEVEL 13. 2003 8:49 Phi
JAN 16. 2004 9:21 AM SEP 13. 2003 1:09 PM FUEL ALARhI
~ NGV i7. 2003
~ 5:41 RM NOV ib. 200I 7:22 FM FEB 9. 2003 3.:3'~ PM
MAX PRODUCT ALARM SEF 4. .2001 2:1.2 PM
SEP 24. 2002 @:il AM PROBE GUT
MAY 20, 2002 4:17 AM NOV 6, 2002 8:2b FM
SEP 20. 2001 8:32 FM NOV 6. .2002 7:20 PM
tVOV 6. 2002 b : 4'5 PM
n ~ ~ * END ~ ~ ~ * x
~ ~ END * * ~ ~
ALARM MI;STORY REPORT
ALARNI
- -----
L
3:SUPER STP
STP SUMP
FUEL ALARM
ALARM HISTORY REPORT APR 1. 2004 12:11 PM
ALAR M HISTORY REPORT
---- IN-TAN}; ALARM ----- FUEL ALARM
T 2:PLUS UNLD
L 1: - SENSGR
REG STP ALARM ----_ Mf-iR 29, 2004 6:25 PM
STP SUMP FUEL ALr~iRM
INVALID FUEL LEVEL FUEL ALARM JAN 27. 2004 6:02 PM
.IAN 19. 2004 4:09 PM APR 1. :2004 12:13 FM
AUu 28. 2003 4 : X19 PM
NOV 8. 2001 5:35 PM FUEL ALARM
JUL 25. 2003 8:35 .At°1
DELIVER' NEEDED FUEL ALARM
JAN 20, 2004 7:.22 AM FEB 13. 2003 8:51 FM
AUG 29. 2003 5:57 AM
NGV 10, 2001 10:34 AM
~ ~ ~ ~ END ~ ~€ ~ ~
EtVD
TANK LEAK TEST HISTORY
T 2 :PLUS U(VLD
LAST GROSS TEST PASSED:
MAR 29. 2004 12:01 AM
STARTING VOLUME= '2563
PERCENT VOLUME = 25.8
TEST TYPE = STANDARD
LAST ANNUAL TEST PASSED:
IVO TEST PASSED
FULLEST ANNUAL TEST PASS
NO TEST PASSED
LAST PERIODIC TEST DHSS:
MHR 22. 2004 12:01 AM
TEST LENGTH 2 HOURS
STARTING VOLUME= 2837
PERCENT VOLUME = 28.6
TEST TYPE = STANDARD
FULLEST PERIODICs TEST
PASSED EACH .MONTH:
JAN 13. 20103 12:01 H{°1
TEST LENGTH 2 HOURS
.STARTING VOLUME= 3:104
PERCENT VOLUME _ '31._3
TEST TYPE = STANDARD
FEB 16. 2004 1'2:01 AM
TEST LENGTH 2 HOURS
STARTING VOLUME= 3878
PERCENT VOLUME = 39.1
TEST TYPE = STANDARD
MAR 22. 2004 12:Oi:AM
TEST LENGTH 2 .HOURS
STARTING VOLUME= 28'37
PERCENT VOLUME = 28.6
TEST TYP£ = STANDARD
APR 7. 2003 12:01 AM
TEST LENC;TH 2 HOURS
STARTING VOLUME= 38.40
PERCENT VOLUME _ :38,7
TEST TYPE = STANDARD
MAY 12, 2C7D3 12:t~1 AI"1
TEST LENGTH 2 HOURS
.STARTING VOLUME= 2976
PERCENT VOLUME = 30..0
TEST TYPE = STANDARD
JUN 23, 2003 12:01 AM
TEST LENGTH 2 .HOURS
STARTING VOLUME= 4641
PERCENT VOLUME 46.7
TEST TYFE = STANDARD
•
AUG 4. 2003 12:01 AM
TEST LENGTH 2 HOUR2722
STARTING VOLUME= 27,4
PERCENT VOLUME _
TEST TYPE = STANDARD
SEP 22. 2D03 12:01 AM
TEST LENGTH 2:HOURS
STARTING VOLUME= 316
PERCENT VOLUME _
TEST TYPE = STANDARD
OCT 6. 2003 12:01 AM
TEST LENGTH 2 HOURS
STARTING VOLUME= 34'58
PERCENT VOLUME = 34.8
TEST TYPE = STANDARD
NOV 10. 2003 12:01 AM
TEST LENGTH 2 :HOURS
STARTING VOLUME= 3777
PERCENT VOLUME = 38.0
TEST TYPE = STANDARD
DEC i. 2003 12:01 AM
TEST LENGTH 2 HOURS
STARTING VOLUME= 329.2
PERCENT VOLUME = 33.2
TEST TYPE = STANDARD
* * ~ ~ x END * * ~€ ~ ~:
APR 7. 2003 l'2 :D1 AM
TEST LENGTH 2 HOURS
STARTING VOLUME= 2932
PERCENT VOLUME = 29.5
TEST TYPE = STANDARD
MAY 12. 2003 12:01 AM
TEST LENGTH 2 HOUR~475
STARTING VOLUME= 35.0
FERCENT VOLUME _
TEST TYPE = STANDARD
JUN 3. 2002 12:01 AM
TEST LENGTIi 2 HOURS
START 1 Nu^ VOLUME= 3±;192
PERCENT Vt>LUME = 39.2
TEST TYPE = STANDARD
.AUG 12. '2002 '1°2:01 AM
TEST LENGTH 2 HOURS
STARTING VOLUME= 315y
PERCENT VOLUME _
TEST TYP£ = STANDARD
SEP 23. 20D2 12:01 AN1
TEST LENGTH 2 HOURS
STARTI:Ni, VOLUME= 3150
PERCENT VOLUINE = 31.7
TEST TYPE = STANDARD
.,~ IVOV 10. .2003 -12:01 AM
TEST LENGTH 2 HOURS
STARTING VOLUME= 3111
PERCENT VOLUME = 31.'3
TEST TYPE = STANDARD
TANK LEAK TEST 'HI'STORY
T 3:SUPER UNLD
LAST u^ROSS TEST PASSED:
MAR 29. .2004 1'2:01 AM
STARTING tIOLUME= 1988
PERCENT VOLUME = 20.0
TEST TYPE= STANDARD
LAST .ANNUAL TEST PASSED:
NO TEST FASSED
FULLEST ANNUAL TEST PASS
NO TEST PASSED
LAST PERIODIC TEST 'PASS:
DEC 22. 2DD3 1.2:01 AM
TEST LENGTH 2 HOURS
STARTING VOLUME= ~~ ~
PERCENT VOLi1ME _
TEST 'TYPE _ STANDARD
DEC 15.. ,2003 12:Gi AM
TEST LENGTH 2 'HOURS
STARTINGVOLUME= 3121
PERCENT VOLUME = 3i.~4
TEST TYPE = STANDARD
~ ~ ~ ~ ~ END ~ * ~ x
.ALARM HI.STOR`f REPORT
SYSTEP~1 ALARM
PAPER OUT
MAR 5. 2004 12:28 AM
PRINTER ERROR
:MAR 5. 2004 12:?8 AM
BATTERY iS 4FF
JAN 1. 1'996 8::00 AM
CLOGK IS2IUQ20R2E~ PM
JUL 19.
FULLEST PERIODIC TEST
PASSED EACH ~MONTti:
JUL 7. 2003 12:01 AP9
TEST LENGTH 2 HOURS JAN 20, 2003 12:01 AM
STARTING VOLUME= 31 u5 TEST LENGTH 2 F1Ul1RS
PERCENT VOLUME 31.3 STARTING VOLUME= 3076
TCG+'r T~/nr _ n•r.. n.nnrln T.•••,•• .ten • • •,••~• ~•• ~
OUTPUT RELt~Y SETUP
R 1 : REG STP RELA'!
TYPE:
STANDARD
NORMALLY CLOSED
LI9UID SENSOR ALMS
L 1:FUEL ALARM
L 4:FUEL ALARM
L 5:FUEL ALARM
L 6:FUEL ALARM
L 7:FUEL ALARM
L 1:SENSOR OUT ALARM
L 4:SENSOR OUT ALARM
L 5:SENSOR OUT ALARM
L 6:SENSOR OUT ALARM
L 7:SENSOR OUT ALARM
L 1:SHORT ALARM
L 4:SHORT ALARM
L S:SHORT ALARM
L 6:SHORT ALARM
L 7:SHORT ALARM
R 2:PLUS STP RELAY
TYFE:
STANDARD
NORMALLY CLOSED
L I GU I D SENSOR ALh1S
L 2 :FUEL ALARI°i
L 4:FUEL ALARM
L S:FUEL ALARM
L 6:FUEL ALARM
L 7:FUEL ALARM
L 2:SENSOR OUT ALARI°1
L 4:SENSOR OUT ALARM
L 5:SENSOR OUT ALARM
L 6:SENSOk OUT ALARM
L 7:SENSOR OUT ALARM
L 2:SHORT .ALARM
L 4:SHORT ALARM
L S:SHORT ALARM
L 6:SHORT ALARM
L 7:SHORT ALARM
R 3:SUPEP STP RELAY
TYPE:
STANDARD
NORMALLY CLOSED
LIt~UID SENSOR ALMS
L 3:FUEL ALARM
L 4:FUEL ALARhI
L 5:FUEL ALARM
L 6:FUEL ALARM
L 7:FUEL ALARM
L 3:SENSUR OUT ALARM
L 4:SENSOR OUT ALARM
L 5:SENSOR OUT ALARM
L 6:SENSOR OUT ALARM
L 7:SENSOR OUT ALARM
L 3:SHORT ALARM
L 4:SHORT ALARM
L 5:SHORT ALARM
L 6:SHORT ALARM
L 7:SHORT:ALARM
SOFTWARE REVISION LEVEL
VERSION 16.04
SOFTWARE# 346016-100-E
CREATED - 98.08.03.18.43
S-MODULE# 330160-002-A
SYSTEM FEATURES:
PERIODIC IN-TANK. TESTS
ANNUAL IN-TANK TESTS
CSLD
TAN}: LEAK TEST HISTORY
T I:REG UNLD
LAST GROSS TEST PASSED:
MAR 8. 2004 12:01 AM
STARTING VOLUME= 1641
PERCENT VOLUME = 16.5
TEST TYPE = STANDARD
LAST ANNUAL TEST PASSED:
NO TEST PASSED
FULLEST ANNUAL TE-`T PASS
NO TEST PASSED ~
LAST PERIODIC TEST PASS:
FEB 16, 2004 12:O1.AM
TEST LENGTH 2 HOURS
STARTING VOLUME= 4184
PERCENT VOLUME = 42.1
TEST TYPE = STANDARD
FULLEST FERIODLC TEST
PASSED EACH MONTH:
JAN 5. 2004 12:01 AM
TEST -LENGTH 2 HOURS
STARTING VOLUME= 691.3
PERCENT VOLUME 69.6
TEST TYPE = STANDARD
FEB 9. 2004 12::01 AM
TEST LENGTH 2 ,Ht?URS
STARTI~Nu^ VOLUME= 5156
PERCENT VOLUME = 51.9
TEST TYPE = STANDARD
MAR 1.8 . 2002 I.2 : X01 Ahl
-TEST LENGTH 2,HOURS
STARTING VOLUME= 7086
PERCENT 'VOLUME = 71 .4
TEST TYPE = STANDARD
APR 28. 2003 12:O1,AM
TEST LENGTH 2 HOURS
STARTING VOLUME= 6318
PERCENT VOLUME = 63.6
TEST TYFE = STt=iNDARD
MAY 12. 2003 12:01 Af°t
TEST LENGTH 2 HOURS
STARTING VOLUME= 7695
PERCENT VOLUME = 77.5
TEST TYPE = STANDARD
JUN 16. 2003 12:01 AM
TEST LENGTH 2 HOURS
STARTING VOLUME= 8181
PERCENT VOLUME = 82.4
TEST TYPE = STANDARD
JUL 7. 2003 12:01 Ahi
TEST LENGTH 2 HOURS
STARTING VOLUME= 5013
PERCENT VOLUIME = 50.5
TEST T'!PE = STANDARD
AUG 25. 2003 12:01 AtM
TEST LENGTH 2 HOURS
STARTINr, VOLUME= 6893
PERCENT VOLUME = 69.4
TEST TYPE = STAIDARD
SEF 29. 2003 12:01 AM
TEST LENGTH 2 HOURS
STARTING VOLUME= .7301
PERCENT VOLW~"IE = 73.5
TEST TYPE = STANDARD
OGT 20. 2003 i'?:Oi AM
TEST LENGTH 2 HOURS
START I'NG 'VOLUME= 6542
PERCENT VOLUME = 65..9
TEST TYPE = STANDARD
NOV 10. 2003 1 '~' : 01 F1M
TEST LEtdGTH 2 HOURS
STARTING VOLUME= 3531
PERCENT VOLUME _ .35.6
TEST TYPE STANDARD
:DEC 1. 2003 12:01 AM
TEST LENGTH 2 HOURS
STARTI:NG'VOL'UME= -697:0
PERCENT VOLUME = 70.2
TEST TYPE = STANDARD
* ~€ * * ~ END
T 2:PLUS UNLD
PRODUCT CODE 2
THERMAL COEFF :.000700
TANK DIAMETER 95.00
TANK PROFILE 1 PT
FULL VOL 9930
FLOAT SIZE: 4.0 IN. 8496
WATEk WARN I tVG 2.0
HIGH WATER LIMIT: 4.0
MAC; OR LABEL VOL : 9930
OVERFILL LIMIT 95%~
9433
HIGH PRODUCT 90%
8937
DELIVERY LIMIT 4i
397
LOW PRODUCT 300
LEAK ALARt°1 L I MI I T : 99
SUDDEN LOSS LIPIIT: 99
TANK TILT 0.50
MAId I FOLDED TANKS
T#: NONE
LEAK MIN PERIODIC: Oo
0
LEAK MIN ANNUAL Oi
0
PERIODIC TEST TYPE
STANDARD
ANNUAL TEST FAIL
ALARM DISABLED
PERIODIC TEST FAIL
ALARM DISABLED
GROSS TEST FAIL
ALARM DISABLED
ANN TEST AVERAGING: OFF
FER TEST AVERAGING: OFF
TANK TEST NOTIFY: OFF
TNK TST SIPHON BREAK:OFF
DELIVERY DELAY 15 MIN
~~
T :~ : UF'Ek U1VLD
FRc:UUUCT CODE 3
THERMAL COEFF :.000700
TANK DIAMETER 95.00
TANK PROFILE 1 FT
FULL VOL 9930
FLOAT SIZE: 4.0 IN. 8496
WATER WARNING 2.0
HIGH WATER LIMIT: 4.0
MAk: OR LABEL VOL: y930
OVERFILL LIMIT 95i
. 9433
HIGH PRODUCT 90~
. 8937
DELIVERY LIMIT 40
- _ 397
LOW PRODUCT 300
LEAK ALARM LIMIT: 99
SUDDEN LOSS LIMIT: 99
TANK TILT 1.00
MANIFOLDED TANKS
T#: NONE
LEAK MIN PERIODIC: Oa
• 0
LEAK MIN ANNUAL Or
. 0
FER I OU I C TEST T~'PE
STAtdL1~1kD
ANNUAL TEST FAIL
ALARM DISABLED
PERIODIC TEST FAIL
ALARM DISABLED
GROSS TEST FAIL
ALARM DISABLED
ANN TEST AVERAGING: OFF
FER TEST AVERAGING: OFF
TANK TEST NOTIFY: OFF
TNK TST SIPHON BREAK:OFF
DELIVERY DELAY 15 MIN
LEAK TEST METHOD
TEST WEEKLY ALL TANK
MON
START TIME 12:01 AM
TEST RATE :0.2D GAL.iHR
DURATION 2 HOURS
•
LIC~UID SENSOR SETUP
L I:kEG STF
TRI-STATE (SItVGLE FLOAT)
CATE(UOR~' STF SUMP
L 2:PLUS STP
TRI-STATE {SINc;LE FLOAT)
CATEGORY STP SUMP
L 3:SUPEk STP
TRI-STATE {SINGLE FLOAT)
CATEGORY STF SUMP
L 4:DISP FAN 1-2
Tki-STATE {SItVGLE FLOAT)
CATEGORY DISPENSER FAN
L 5:DISP PAN 3-4
TRI-STATE {SlNiaLE FLUAT)
CATEGORY DISPENSER FAN
L 6:DISP PAN 5-b
TRI-STATE {StNt;LE FLOAT)
CATEGORY DISPENSER PAN
L 7:DISF PAIV 7-8
TRI-STATE (SINGLE FLOAT)
CATEGORY DISPENSER PAtV
LEAK TEST REPORT Fc il?MAT
----r---~-- -- ' •
___-- SENSOR ALARM -----
L 6:DISP PAN 5-6
DISPENSER PAN
FUEL ALARM
APR 1, 2004 12:17 PM
-- SENSi}R ALARM -----
L 3:SUPER STP
STP SUMF
FUEL ALARM
~iPR 1, 2004 12:11 FM
IN-TANK SETUP
T 1:REG UNLD
PRODUCT CODE ;
THERMAL COEFF :.000700
TANK DIAMETEk 95.I~0
TANK PkOFILE 1 FT
FULL VOL 9930
FLOAT SIZE: 4.0 IPJ. 849E
L 1:REG STP
STF SUMF
FUEL ALARM
APR i, 2004 12:13 PM
WATER WARNING 2.0
HIGH WATER LIMIT: 4.0
MAX QR LABEL VOL: 9930
OVERFILL LIMIT ~5i
9433
NIGH PRODUCT 90r~
. 8937
DELIVERY LIMIT 4i
. 397
LOW PRODUCT 300
LEAK ALARt°I L I I°t I T: 99
SUDDEN LOSS LIMIT: 99
TANK TILT 0.50
MANIFOLDED TAtVKS
Tit : NONE
LEAK MIN PERIODIC: Oi
. 0
~ LEAK M [ N AfVNUAL 0:v
0
SYSTEM SETUP - - - - _ _
APR 1: 2001 12::18 PM
-- SENStiR ALARM -----
L 2:I'LUS STP
STP SUMP
FUEL ALARM
APR 1, 2004 12:13 PM
----- SENSOR ALARM -----
L q:DISP PHN i-'?
DISPENSER PAN
FUEL ALARM
APR 1, 2004 12:18 PM
PERIODIC- TEST T~'PE
STAtVDARD
SENSOR ALARM
L 5:DISF PAN 3-4
DISPENSER PAN
FUEL ALARI°1
APR i , 200: i 2: 1 ` Fr9
- SENSOR ALf=+;; 1 ----'
L 7:DIaP FAN 7-8
UISPENSFR PAtV
FUEL ALARM
APR 1 , 2004 12:16 PP'I
SYSTEM UNITS
U.S.
SYSTEM Li=tNGUAGE
ENGLISH
SYSTEM DATE!T II°lE FURMAT
MON DD YY'YY FtH:r.~ :SS ~M
BEACt}N LIQUOR
E495 S. UNION
hAY,ERSFiELD, CA
661-832-3222
SHIFT TIME 1 6:DO AM
SHIFT TIME 2 : DISABLED
SHIFT TIME 3 DISABLED
SHIFT TIME 4 : DISABLED
TANK PERIODIC WARNINGS
DISABLED
TANK ANNUAL WARNINGS
DISABLED
LINE PERIODIC WARNINGS
DISABLED
LINE ANNUAL W-=jkN:NGS~
DISABLED
FR I NT TC VOLUrIE:~
ENABLED
TEMP COMPENSATION
ANNUAL TEST FAIL
ALARM DISABLED
PERIODIC TEST FAIL
ALARM DISABLED
GROSS TEST FAIL
ALARM DISABLED
ANN TEST AL'ERAG I IVG : OFF
PER TEST AVERAGING: OFF
TA NI; TEST NOT I Fj' : OFF
TNK TST SIPHON BREAK:OFF
DELIVERY DELA`1 15 MIN
~~
`rte ; I i
~'
UNDERGRpU~4Q STORAGE TANKS ~
~_. ~.. N: - ~.. r _~. ~s-
~wr~r r
~p~LicAr~a.rv
~r0 PERFORM ~I:D / LiN~ TESTING
/ S6989 SE ONDARY CONTAINMENT TESTING
/TANK' TIGNE~S TESh' IAND TO PERFORM FUEL
MONfTOR1 'C R7lFIQATION
BAKERSFIELD FIRE DEPT.
~'reventian Services
~JUU "I~ruxttul .A~e., Stc.::
131-:~t-~rl~:<<.i. c:r~ ~~:~(> >
Fax: {661) 852-2171
~?a9e t of t
PL=iaMIT NO. L ~~~'~~,
~ j,
^ ENHANCED LE K ETECTION ^ uNE TESTING ~ 5B-989 SECOrJDARY CONTAiNMEr; i .'c:S71NG
^ TANK TIGHTN ~S~EBT ^ TO PERFORM FUEL MONITORING CER7iFtCATION
~, SITE INFORMATION -_ __ __
~ A ~~.ITY / NAME & PHONE NUh1EER OF CONTACT PERSON
~wt~~l~ss 3~~ ~ ' J. C~~___.__
~ ~o i ___.__ . __._.~ ...~ ____.~._._ ,3 3,0. ~ ..____.__ ___ _ __. ----_-_-. - -.__.--
UVd,NERS NAME
,OP(ERATORS NAME ,PERMIT TO OPERATE NO.
i 1
PtUP•ALiLR OF'rANKS`TO BE TESTED S ~%IPIFJG <.;UItdG'CQ 3(. TESiE_D"'
_.. TA_N:Lt...a. VOLUME
~i
_ f_ ~._~____; ~ ~''a ~._~.~;_ _____._ ~_.__~_
~ ~, ~
TANK TESTING COMPANY
_..____..___.__._._ .. -- -- ..----..._._T___._..____.
NA OF TESTING GOfytPANV ~ t~Al ~ PHONE NUtAC3ER UP CONTACT PERSON
G~ ~~ ~w ~ _,~~ -c.,~. __..... ~.~~~~cl-~.... ~wn.a-~.~, to ~ l - ~3 ~-.~ 9 9,.
MAILI G AODRESS~_
~d=-~-~-~? -~---- _ ~ 9 330 _ _ _ _ _ ____ _ __ _
NAM & PHONE NUMBER OF TESTER OR ECIAL ~NSPECTOR CERTIFICATION u: ~ - -
DA & TIME TEST°TO BE CONDUCTED -CC a ^~
SIGNATURE OF AP GANT - DATE
__._. _ _ .. ~ ~~~~Q S
______ _~___ T tS APPI.IGATIC}N 86GQME~ A P~R~c1.l H. N A4'PRQYEU
Ai=~PIlCJVED 8Y UA7E
_ ____ _ __-_ _.~.__----.---.----------__.._--t.Q~ ~ a~__-- _-_ __ _ __-- _ __ ----- _ ___
~.
r,
-~o~;C~
~~I~LING & PERMIT STATEMENT
Bakersfield Five Dept.
PREVENTION SERVICES
Fire Safety Services • Environmental Services
1715 Chester Ave
Bakersfield, CA 93301
Tel: (661)326-3979
~..
UST n57 PERr.tiT, TANK TESTING ° ~^ ~~ ~ r- 82
• - 53
-STATE SURCHARGE 86
~ R . 4 1 ..
/
~
84.
TENTS, LPG, FIREWORKS..P.,OWDER/OTHER PERMITS COPIES/REPORTS 69
FOLLOW-UP' INSPECTION
INSPECTOR: DATE
TIME SPENT: CHARGES: CHARGES CODE:
-
REASON and DATE
~
..-'t ~~
i _. ~:;w- - FOR INSPECTION: -
LOCATION OF INSPECTION ~ -
r}
BUSINESS.NAME: - ~ _ ,.
TELEFHONE NUMBERS}: ~
~ p
/ t
t~
BILL TO ~ - '_~ PAY:BY y,~ <
:, _
,.
i
~ -
4 '
}~
~
t
NOTES:
,, _ -
CUSTOMER SIGNATURE INSPEC ` R/RECENER SIGNATURE ~'I .. - -
q""'~ " '` FD1734 rev.12103
\~'~ ' ^ \ ~'~,`: ~ ~-.cL', , ~;''~ 4', o~. ORIGINAL WHITE: FINANCE _ CUSTOMER PINK OFFICE YELLOW
work pazpced: BY: - Print Name}
rate: Company
s~~mre: Date
tceaw~eTecn Josh, Jim
Is arldviaoal work requircdT Yes NO
~~:
wmktrr ce completed: Redwine to puA permit
Test results sent to: Client:
Regulatory Agency: